PHLEBOTOMYOBJECTIVES1. Theory and practice of phlebotomy2. How to interact professionally with the patient3. Occupational health hazard and the appropriate safety precaution4. Ideal blood collection site during venipuncture5. Materials to prepare during venipuncture6. Different phlebotomy procedures7. Complications that may occurTHEORY AND PRACTICE OF PHLEBOTOMY Ancient practice of blood letting Withdraw of blood from a vein, artery or the capillary bed for lab analysis or blood transfusion Venipuncture is under phlebotomyPHLEBOTOMIST Trained to collect blood and other specimens Prepare specimen for testing Interacts with the patient and healthcare professionals Plays a vital role in patient managementLAB WORKFLOW CYCLE

PROFESIOLANLISM1. Confidentiality Avoid gossiping about the patient

2. Attitude Tone of voice and facial expression will determine how patient will respond to you Always be polite, friendly, calm and considerate

3. Image Appearance Your personal appearance will also affect the impression

4. SafetyBLOOD BORNE PATHOGENS Infectious microorganism which live in bloodstream You can be exposed to: HEPA B, HIV, HEPA CSAFETY PRECAUTIONS1. Standard precautions Treat all body fluids as potentially infectious Semen, vaginal discharge, saliva, sputum, peritoneal, pericardial, pleural fluids Sweat & tears are not infectious

2. Personal Protective Equipment Lab coat, gloves, face masks

3. Hand washing Most important infection control measure HAPPY BIRTHDAY 3X: considered as adequate Wash hands before, after and between all patient contacts Be sure to turn off faucets using a paper towel Remove rings Stand by the sink but dont touch it Apply soap and rub Both sides between fingers and around knuckles, under the fingernails Rinse in a downward motion Dry hand by paper towel

4. Hazardous waste disposal All needles and other sharps must be disposed properly.

5. Needle stick prevention act Safety devices should always be encouragedBLOOD COLLECTION SITES common sites: all located at the antecubital fossa (best area to do venipuncture)a) Median cubital: Best vein to target, well anchored, prevent the vein from rollingb) Cephalic: potential for rollingc) Basilic: last option, potential for rolling and very painful

BLOOD COMPONENTS Circulating Whole Blood is a mix of plasma and cellular components

PLASMA Centrifuged whole blood Plasma, buffy coat (wbc and platelet) , rbcBLOOD CLOT When a blood sample is left standing without anticoagulant

SERUM Centrifuged whole blood with no anticoagulant Contains same substance as plasma except for the coagulation proteins because they are left behind in the blood clotEQUIPMENTS FOR VENIPUNCTURE1. Phlebotomy tray Tubes, syringes, needles, cappilets, alcohol swab, sharp collector, lancets, vacutainer set Always filled out, organized and sanitized

BLOOD COLLECTION TUBES Glass or plastic with a rubber stopper It has a vacuum so that blood will flow into the tube Anticoagulated Rubber stoppers are also color coded It will indicate a different kind of anticoagulant

1. RED No anticoagulant For Blood Bank, Chemistry, Toxicology, Serologic Dont invert after filling

2. LAVENDER Anticoagulant: EDTA ( Ethylene Diamine tetraacetic acid) Hematology studies Glycosylated haemoglobin Should be completely filled Must be inverted after filling (FIGURE OF 8 [8-10 times])

3. LIGHT BLUE Anticoagulant: Sodium Citrate Coagulation studies (clotting studies) Invert immediately after filling

4. GREEN Anticoagulant: Sodium/Lithium Heparin For test requiring whole blood or plasma for the detection of blood ammonia levels

5. GRAY Inhibitor for glycolysis + Anticoagulant Inhibitor: Sodium Flouride + Potassium oxalate (PLASMA) Na EDTA + NaFl (PLASMA) NaFl (SERUM) For glucose, lactate and alcohol determination

6. YELLOW As a blood culture bottle containing antibiotic removing device Or used in other test aside from blood culture Anticoagulant: Acid citrate dextrose Inactivates complements, DNA studies, paternity testing, HLA phenotyping

7. BLACK Anticoagulant: Citrate For Erythrocyte Sedimentation Rate

8. ROYAL BLUE Only the top is colored royal blue but the anticoagulant is dictated by the label Heparin (green), Na EDTA (lavender) or no anticoagulant (red) Designed to contain no contaminating substances For trace elements and toxicology studies

BLOOD CULTURE BOTTLES Blue: aerobic (adult) Lavender: anaerobic (adult) Pink: pedia

SAFETY Rubber stopper and plastic shield to prevent accidental spillSIZESAdult: 3-10 mlPedia: 2-4 mlTubes for fingersticks or heelsticks or lessIt contains Expiration date, amount of blood to be dispensedVACUTAINER SYSTEM It can be used for multiple tubesHOLDERS: A plastic holder must be used with the evacuated tube system

NEEDLE HOLDERS WITH BUILT IN PROTECTIONSYRINGES: tip, barrel, plunger

SYRINGE WITH BUILT IN SAFETY DEVICES

NEEDLE GAUGE: Black- 22, Green-21 Size= gauge (Bore diameter) The larger the needle the smaller the gauge number 21 or 22 are used

NEEDLE COMPONENTS Tip bevel upSINGLE DRAW NEEDLES Needles that come up with syringesMULTIPLE DRAW NEEDLES Needles that come up with the vacutainer systemNEEDLES WITH BUILT IN SAFETY DEVICES An internal blunt needle that is activated with pressure once the last tube has been filled Automatically move forward significantly decreasing the risk for needle stick injuryBUTTERFLY NEEDLE Winged infusion set Difficult venipunctures including pediatric draws With a syringe or a holder and vacuum collection tube system 21,23,25 gauge

BUTTERFLY WITH BUILT IN SAFETY FEATURES Number one cause of needle stick injuryLANCETS Difficult venipunctures including pediatric draws

OTHER MATERIALS: TOURNIQUES STERILE ALCOHOL PADS BANDAGING MATERIALS: micropore GLOVES: worn for all procedures requiring vascular access, non-powdered latex gloves SHARP DISPOSAL BIN MARKING PENTECHNIQUE OF VENIPUNCTURE1. GREETING Always greet the patient in a professional friendly manner Good initial impression will earn the patient trust and makes it easier and more pleasant to draw a good specimen Identify the patient correctly Identify yourself Good verbal, listening skills

2. PATIENT IDENTIFICATION Name, medical record number, date of birth or order/ requisition match those on the patient armband Verify the name of the patient by asking his/her full name Properly identify patient and specimen labelling Never rely in the patients name on the door or above the bed. Patients are frequently moved from one room to room

3. POSITION THE PATIENT Comfortable position Avoid hyperextending the elbow (difficult palpation)

4. APPLYING THE TOURNIQUE 3-4 Fingerbreadths above the elbow Should be tight enough to stop the flow of blood 1-2 minutes Make a fist and not pumping because it can cause hemoconcentration

5. CHOOSE A SITE Median cubital vein If not accessible use cephalic or basilica vein If not accessible: veins on the back of the hands Use a much smaller needle for smaller veins Non dominant hand for palpation of the veinNEVER DRAW FROM THESE AREAS Scarred, abraided or inflamed skin Arms containing IV catheters : Pricking or close the unimportant IV line Edematous sites (prick) Occluded or sclerotic veins (prick or access other veins) Shunts/ fistula: can dislodge the AVF

6. CLEASING THE SITE Isopropyl alcohol swab Outward expanding spiral starting with the actual venepuncture site Allow the alcohol to dry (wet area can cause painful venepuncture)

7. ATTACH NEEDLE HOLDER Insert needle in 15 degree angle Insert the tube Correct Blood to anticoagulant ratio

8. BLOOD WONT FLOW May not be in the vein Through and through Vein not hit Needle is in the wall of the vein

TROUBLESHOOTING Push the needle forward or backward Adjust the angle Loosen the tourniquet Try another tube Re-anchor the vein: Hold the vein in two sides and guide your needle

OTHER PROBLEMS Hematoma Arterial blood collected: apply firm pressure for more than 5 mins. Make sure bleeding has stopped before leaving the patient

MULTIPLE TUBE COLLECTIONORDER OF DRAW: Vacutainer systemTo avoid the contamination of the anticoagulant from other tube.I. Sterile/ Blood culturesII. BlueIII. RedIV. Serum separator tube (yellow)V. Other:a. Greenb. Lavenderc. Grayd. Yellowe. Black

9. REMOVING THE NEEDLE Release the tourniquet before withdrawing the needle Withdraw needle in a single quick movement Apply pressure Bandage Dispose sharps and hazardous waste in proper containers Label specimen at the bedside (first and last name of the patient, date and time of collection, initials of the phlebotomist) Wash hands

10. THANK THE PATIENT

SYRINGE SPECIMEN COLLECTION-for patients with delicate veinsFINGERSTICK-SPECIMEN COLLECTION Safety lancet : manufactured to control the depth and to minimize trauma Fingerstick should not be performed in children under 1 year old instead do heelstick

FINGERSTICK 4th (ring)/ middle finger Puncture should be done perpendicular to the finger print Discard the first drop of blood (contain tissue fluids)

HEELSTICK Small children and infants Use the sides of the foot Discard first drop of blood Dont apply adhesive tape or bandages because it can cause contact dermatitis to the baby

BUTTERFLY Same principle usedWHAT TO DO?1. PATIENT REFUSING BLOOD WORK Convince the patient Inform the nurse and the patient will be asked to sign a refusal for venipuncture

2. FAINTING Lie down and put a pillow beneath the knees Monitor pulse rate and blood pressure If the patient is seated: Place the head between the knees Apply cold compress

3. UNSATISFATORY SPECIMENS Misleading results Rejected Do another venipunctureCAUSES: HEMOLYZED, CLOTTED, INSUFICIENT, MISLABLEDHEMOLYSIS Too small needle for a relative bigger vein Pulling the plunger too rapidly Dispensing the blood to the tube rapidly Shaking of the tube too hard

CLOT Inadequate mixing Delay in expelling of bloodINSUFICIENT VOLUME Vein collapse Needle coming out Loss of vacuum in the tubeLABELLING ERRORS Most common cause of errors Immediately rejected CAUSES: failure to identify the patient correctly, not labelled the specimen properly after collection

10 COMMANDMENTS IN VENIPUNCTURE1. Thou shall protect thyself from injury2. Thou shall identify thy patient3. Thou shall stretch the skin of the puncture site4. Thou shall puncture skin at about a 15 degree angle5. Thou shall glorify the median vein6. Thou shall invert tubes containing anticoagulant immediately after collection7. Thou shalt attempt to collect specimen only from an acceptable site8. Thou shall label specimen at the bed side9. Thou shall know when to quit10. Thou shall treat patient like they are family.